What is contraception?

Also known as ‘birth control’, contraception is the term used when action is taken to prevent a pregnancy. [1] There are several different types of contraception available in Australia, including physical barriers and devices, hormonal (oral, implant and injectable) methods, sterilisation, emergency and ‘natural’ methods. [2]

Despite nearly 70 percent of Australian women of reproductive age using a contraceptive method, estimates are that more than 50 percent of Australian women have had an unplanned pregnancy. This rate, similar to that in the United Kingdom (30 percent) and United States (49 percent). [3]

Types of contraception: Barrier

Condoms (male and female)

Condoms are a form of barrier contraception. They prevent pregnancy by stopping sperm from reaching and fertilising an egg. Condoms also provide protection against STIs, including HIV, and stop them being passed from one sexual partner to another. Condoms are used during penetrative sex (vaginal or anal) and oral sex to protect against STIs. [4]

The male condom is a latex (or polyurethane) sheath that covers the erect penis and prevents semen entering the vagina. The male condom is 98 percent effective when used correctly. The female condom is a loose polyurethane sheath with a flexible ring at each end that sits in the vagina and collects semen. It can be inserted several hours before intercourse and is stronger than the male latex condom, though insertion and use may take some practice. If you use a female condom correctly every time you have sex, they are 95 percent effective. [5]

Diaphragm or cup/cap

A diaphragm is a shallow silicone cup inserted into the vagina to prevent pregnancy. In order to be as effective as possible, the diaphragm must be used with spermicide cream, gel or jelly.

Types of contraception: Hormonal contraception

Oral

Combined contraceptive pill

Usually just referred to as ‘the pill’, it contains synthetic (man-made) versions of the female hormones oestrogen and progesterone, which women produce naturally in their ovaries. [7] The pill works by preventing the uterus from releasing an ovum (egg) each month. It also thickens the mucus in the cervix, preventing sperm from getting through. If used correctly, the combined pill is 99.7 percent effective in preventing a pregnancy.

The combined pill must be taken every day, at around the same time, and vomiting and severe diarrhoea can interfere with absorption. Side effects can include nausea, breast tenderness, headaches and increased appetite. It can lead to serious complications such as deep vein thrombosis (blood clots), heart attacks and strokes, and is not suitable for women who have certain medical conditions (for example, certain types of migraines, high blood pressure, severe heart conditions or liver disease). It is not recommended for women who are very overweight or who smoke and are aged over 35 years. It does not provide protection from sexually transmissible infections (STIs). [8]

Progestegon-only (POP) or ‘mini’ pill

This pill contains only one hormone, progestogen. It works by thickening the mucous at the neck of the womb and thinning the lining of the uterus to reduce the chance of pregnancy. [9]

In some women it also stops the release of an egg each month. The POP is useful for women who cannot use the Combined Oral Contraceptive Pill (eg, those who are over 35 or breastfeeding) and, when used correctly, is around 99 percent effective in preventing pregnancy. However, this means it must be taken every day at the same time – if you are more than three hours late in taking the POP, you are not covered for contraception. Once you stop taking the POP, your fertility returns to your normal level immediately. There are few side effects to the POP – the most likely side effect is irregular bleeding. It does not protect against STIs. [10]

Hormonal contraception: Other

Vaginal ring

This is a soft plastic ring that contains the hormones oestrogen and a progestogen, similar to the Combined Oral Contraceptive Pill (the Pill). It is placed in your vagina and the hormones are absorbed into the body to stop you getting pregnant. It works by stopping your ovaries from releasing an egg. The vaginal ring is inserted for three weeks, and then removed for one, before a new ring is inserted. With perfect use, the vaginal ring is 99 percent effective. In ‘real use’, however, it is less effective with up to nine women in every 100 becoming pregnant in a year – you need to remember to take it out and put in a new one at the right time. In Australia, the only contraceptive vaginal ring available is called a NuvaRing®. [11]

Implants and injections

Implanon is a hormonal implant the size of a matchstick, which is inserted under the skin at the inner side of the upper arm. This 4cm-long implant contains etonogestrel, a progesterone-like hormone that prevents ovulation. This hormone also thickens the mucus in the cervix (entrance to the uterus), preventing sperm from getting through. The device is inserted under local anaesthetic by a doctor. Implanon is close to 100 percent effective and lasts for three years. Side effects may include breakthrough bleeding, headaches, acne, breast tenderness or increased appetite.

Depo-Provera and Depo-Ralovera are long-acting, injectable contraceptives that contain only the synthetic form of progesterone, called Depot Medroxyprogesterone Acetate (DMPA). Each injection of DMPA prevents an unplanned pregnancy for 12 to 14 weeks.

Injectable contraceptives prevent ovulation and thicken the mucus in the cervix, preventing sperm from getting through. They also cause changes to the lining of the uterus, making it difficult for a fertilised egg to stick. Injectable contraceptives can also be used to treat women with menstrual problems.

You will need to talk with your doctor or healthcare provider before you start using DMPA, as this form of contraception isn’t suitable for all women.

Around 50 percent of women using injectable contraceptives don’t have periods, which some women see as an advantage. However, DMPA injections can’t be reversed or withdrawn, so side effects, including weight gain, headaches or depression, may last 12-14 weeks. [12]

Types of contraception: Other

Billings method

The Billings method is a form of natural family planning that teaches a woman to interpret her signs of fertility. It doesn’t rely on any drugs or devices, and there are no side effects. A couple can either avoid or achieve a pregnancy once they understand how to identify fertile and infertile times during the woman’s menstrual cycle.

This is a cooperative method of family planning that puts the responsibility equally on both partners. Its success depends on the woman learning to understand her own individual pattern of fertility and the couple cooperating with the recommendations of the guidelines.

If you pay daily attention to the mucus produced throughout your menstrual cycle, you will notice a pattern including:

In the days following menstruation, you may either feel dry or notice a consistent pattern of discharge (infertile phase).

Then you observe a change from the infertile phase, either in sensation or the appearance of the mucus. You no longer feel dry (beginning of the fertile phase).

In the days leading up to ovulation, you will notice a changing pattern of sensation and mucus. The vulva will begin to feel slippery (fertile phase).

The last day of the slippery sensation is the peak of fertility. Ovulation occurs no more than 48 hours after the peak.

After the peak, the vulva feels dry or sticky. The woman is infertile from the fourth day past her peak until the next menstruation.

Menstruation occurs 11 to 16 days following the recognition of the peak if the cycle is fertile.

Individual instruction is recommended. There are Billings Method clinics located around Australia, offering detailed training and support – more information here. [13]

Withdrawal method

The withdrawal method is when a man withdraws his penis from a woman’s vagina before he ejaculates. This is meant to prevent sperm entering the vagina, reaching an egg and causing pregnancy. This method is not recommended as the penis produces fluid after it becomes erect and before ejaculation, and there is often sperm in the fluid. Also, this method relies on the man judging when he is going to ejaculate. [14]

Intrauterine contraception

An IUD, sometimes known as a coil, is a small plastic device with added copper or hormones (Mirena) which is inserted into your uterus by a doctor. It can stay in the uterus for five to 10 years (depending on the type used) and can easily be removed earlier if you want to become pregnant or are having problems.

Both types of IUD are more than 99 percent effective. They work by changing the lining and environment of the uterus, effectively killing off sperm. If any sperm survive and fertilise an egg, the egg is unable to stick to the wall of the uterus, preventing a pregnancy from continuing.

The hormonal (Mirena) IUD also slowly and continuously releases a small amount of progestogen, which can thicken the mucus made by the cervix to further block sperm. This may also cause minor effects on the hormones controlling your menstrual cycle. The hormonal IUD (Mirena) is occasionally removed because of hormonal symptoms such as headache, breast tenderness, acne and increased appetite. It does, however, generally result in very light periods. The copper IUD tends to make periods heavier, but doesn’t cause hormonal side effects. [15]

Emergency contraception

A woman can use emergency contraception to prevent pregnancy after having unprotected sex, or if a method of contraception has failed. There are two types of emergency contraception:

the emergency contraceptive pill (sometimes called the morning-after pill)

Sterilisation

This is a permanent surgical procedure that requires referral to a specialist. In females, the fallopian tubes are blocked, preventing an egg from passing down the tube and being fertlised. The two common methods are Tubal ligation and Essure. In men, a vasectomy is performed, involving blocking the sperm by cutting the tubes they pass through from the testes to the penis.

How to choose the contraception method that suits you

The method you choose will depend on a range of factors, such as general health, lifestyle and relationships, your risk of contracting a sexually transmissible infection (STI) and how important it is that you don’t become pregnant.

It’s also important that you consider issues such as effectiveness, safety and adverse effects, weighed against convenience, cost and issues of trust and control. If you decide on the pill, for instance, you need to remember to take it every day, while an implant can last up to three years. [17]

The history of contraception

According to this article from Time magazine, the earliest known methods of birth control date back to an Egyptian manuscript called the ‘Ebers Papyrus’ around 1850BC, which directs women on how to mix dates, acacia and honey into a paste, smear it over wool and use it as a pessary to prevent conception. However, ancient drawings (3000BC) from Egypt clearly depict men wearing condoms – though there is speculation these may have been for ceremonial dress.

While Casanova wrote about using condoms in his memoir (made from lamb intestine) in 1734, it wasn’t until 1844 that Charles Goodyear patented the vulcanization of rubber and rubber condoms were soon mass-produced. [18]

In 1873, the US Congress passed the Comstock laws, making all forms of contraception illegal. However, contraceptive products were still marketed and sold – as feminine hygiene products. [19]

In 1960, the US Food and Drug Administration (FDA) approved the oral contraceptive pill for sale to the American public. Australia followed soon after and was the second country in the world to make the pill available. [20]

In 1992, the FDA approved Depo-Provera, the first hormone shot, and in 1998, the ‘morning after pill’ or emergency contraceptive was approved. [21]

New research

While there is currently no birth control pill for men, scientists believe they are getting closer. According to an article in the journal Proceedings of the National Academy of Sciences, researchers recently identified two proteins that can be blocked to prevent the launch of sperm cells from the testes during ejaculation.

Compared with developing a female pill, designing a male version is a far more difficult process. Most approaches have relied on hormonal targets or rendering sperm dysfunctional. One major problem is ensuring that every one of the millions of sperm cells produced by a man is stopped from carrying out its job of fertilising the female egg, because it takes only one sperm to produce a baby.

Tampering with sperm must also present no risk of altering an offspring’s genetics. In addition, a male oral contraceptive should ideally be readily reversible and leave sexual function unaffected. The new approach appears to tick all these boxes, raising the prospect of a pill for men that is 100 percent reliable and can be taken when needed. [22]

Meanwhile, whether or not the combined pill increases the risk of breast cancer is uncertain. Experts agree that if it does increase the risk, this increase is small. There is a small increase in the risk of cancer of the cervix, but the risk of this cancer is very low in Australia.

The combined pill has been found to reduce the risk of cancer of the ovaries and uterus and may also reduce the risk of bowel cancer. [23]

Religion and contraception

The various Christian churches have different views on contraception:

The Roman Catholic Church says that the use of contraception is against natural law (which means it is not in keeping with human nature). It is natural that conception may happen with intercourse and therefore this should not be prevented. The only form of contraception permitted is the ‘rhythm method’ (Billings method) where intercourse takes place at a time when the woman is least fertile.

Most Protestant churches (eg, the Anglican Church and the Methodist Church) now see the use of contraception within marriage as a responsible way of planning a family. It allows sex to be enjoyed without the fear of an unwanted pregnancy. [24]

Islam: Whilst pre-marital sex is prohibited, a sexual relationship is seen as part of married life, both for the purposes of having children and to ensure that the sexual needs of the couple are satisfied within a legitimate relationship. Contraception has been judged permissible in certain circumstances:

to space child-bearing, thus promoting the health of all children in the family. For example, to protect the health of an existing child who may not yet be weaned

where there is fear for the physical and mental well-being of the mother

for personal reasons dictated by conscience.

Coitus interruptus, the withdrawal method, was practiced by early Muslims with the tacit approval of Prophet Muhammad. Some Muslim jurists have inferred from this that other non-permanent methods such as condoms, cap, IUD and oral contraceptives are also permissible.

Vasectomy is strictly forbidden. Although female sterilisation may be permissible, this is only when there is a medical opinion that the woman’s life would be endangered or her mental health seriously affected by a pregnancy, which could not be prevented by other legitimate means. [25]

Sikhs believe in monogamy and great importance is attached to high moral character, modesty and sexual morality. One of the five Ks (religious symbols) of Sikhs is Kachhahra, which is a special pair of shorts worn as an undergarment by all initiated Sikhs, both men and women. This highlights the importance attached to sexual morality in Sikhism. Traditionally in Sikhism, like many other religions, the family size used to be large. However, attitudes today are beginning to change. Birth control through the use of contraception is an acceptable practice within Sikhism and family size is usually small. As there is no actual religious prohibition, acceptance of family planning has grown in line with social and cultural changes.[26]

Hinduism: All methods of contraception are permitted.

Arguments for family planning can be found in many moral teachings and epic stories such as the Mahabharat which ‘offers great praise for the Pandavas, who served as one of the Hindu prototypes of the ideal family. The Pandavas have small families and are exemplary in meeting the exacting demands of dharma’.

Many Hindus believe that it is their duty to produce a son, since only sons can perform the funeral rites that enable a man’s soul to go to heaven. Sons are therefore needed to say prayers to ensure survival in the next world. A son is known as ‘putra’ – he who saves from hell. Contraception is therefore not generally practiced until the birth of a son or sons. [27]

Buddhism: Most Buddhists believe that conception occurs when the egg is fertilised so contraception that prevents fertilisation is not ordinarily a problem. Emergency contraception is likely to be unacceptable. However, as Buddhism is open to personal interpretation, attitudes to this and other questions of birth control will vary.

When is it safe to stop contraception?

Until menopause is reached, women are not totally protected from pregnancy, despite the decline in fertility during perimenopause. The possibility of pregnancy in women aged 45-49 is estimated to be two or three percent per year. After the age of 50, it is less than one per cent. However, the fertility of individual women is extremely variable, so contraception remains an important consideration at this time. In fact, contraception is recommended until at least one year after menopause for women aged 50 years and over, and for two years for women younger than 50. [29]